Provider Demographics
NPI:1073950671
Name:LUMINIS HEALTH COMMUNITY CLINICS, LLC
Entity Type:Organization
Organization Name:LUMINIS HEALTH COMMUNITY CLINICS, LLC
Other - Org Name:AAMC COMMUNITY CLINICS, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-481-6549
Mailing Address - Street 1:1419 FOREST DR
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21403-1482
Mailing Address - Country:US
Mailing Address - Phone:410-990-0050
Mailing Address - Fax:410-990-0336
Practice Address - Street 1:1419 FOREST DR
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21403-1482
Practice Address - Country:US
Practice Address - Phone:410-990-0050
Practice Address - Fax:410-990-0336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-23
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
303322Medicare PIN